division of aging and adult services€¦ · updated - community action program services (caps) –...

Division of Aging and Adult Services ALERT

SFY-18-K2 Technical Assistance

for SFY 2018 Technical Assistance ALERTS are generated periodically to update contractual and/or programmatic requirements and/or clarifications. Please ensure that appropriate Community Action Agency (CAA) staff are aware of this technical assistance. UPDATED - Community Action Program Services (CAPS) – Income Eligibility Thresholds for SFY 2018 This chart is updated with corrections. The cents are rounded up, rather than to the nearest dollar, per federal guidance. These charts replace the charts issued in the March ALERT, dated March 17, 2017. There are no other changes. The SFY 2018 Income Threshold Chart for CAPS becomes effective on July 1, 2017 and will remain in effect until June 30, 2018. The income threshold for Low Income Home Energy Assistance (LIHEAP) eligibility is set at 60 percent of the current SMI (Attachment #1), as determined by the 2015 American Community Survey (ACS), Five-Year Estimates, or 150 percent of the current Federal Poverty Guideline (FPG) (Attachment #2), whichever is greater. The current FPGs are used to determine income eligibility according to the rules and income limits for each specific program in the Community Action Programs and Services contract. These updated charts will replace the SFY 2017 Income Threshold charts in the LIHEAP and Short-Term Crisis Services (STCS) Policy and Procedure Manuals beginning July 1, 2017. If you have any questions or require additional information, please contact Diana Gravett, Community Action Program Specialist, at [email protected] or (602) 542-6594.

mailto:[email protected]

SFY-18-K1 Attachment 1

3/18/16

Department of Economic Security (DES)

Division of Aging and Adult Services (DAAS) SFY 2018 Simplified LIHEAP Income Chart

Effective July 1, 2017 to June 30, 2018 Revised 6/8/17

60 percent of State Median Income (SMI) is used for households sized 6 and

under

150 percent of Federal Poverty Guideline (FPG) is used for households sized 7

and over

Household Size 30 Day Gross Income Limit (Dollar Amount)

1 SM I60 percent $1,786

2 2,335

3 2,885

4 3,435

5 3,984

6 4,534

7 FPG 150 percent 4,642

8 5,165

9 5,687

10 6,210

11 6,732

12 7,255

For each additional household member, add $522

Arizona Department of Economic Security - Division of Aging and Adult Services (DAAS)

1 2 3 4 5 6 7 8 9 10 11 12 For >12

Add

$753 $1,015 $1,276 $1,537 $1,798 $2,060 $2,321 $2,582 $2,843 $3,105 $3,366 $3,627 $261

$1,005 $1,353 $1,701 $2,050 $2,398 $2,746 $3,095 $3,443 $3,791 $4,140 $4,488 $4,836 $348

$1,256 $1,691 $2,127 $2,562 $2,997 $3,433 $3,868 $4,304 $4,739 $5,175 $5,610 $6,045 $435

$1,507 $2,030 $2,552 $3,075 $3,597 $4,120 $4,642 $5,165 $5,687 $6,210 $6,732 $7,255 $522

$1,786 $2,335 $2,885 $3,435 $3,984 $4,534 $4,642 $5,165 $5,687 $6,210 $6,732 $7,255 $522

1 2 3 4 5 6 7 8 9 10 11 12 For >12

Add

A) 5 points$446 $583 $721 $858 $996 $1,133 $1,160 $1,291 $1,421 $1,552 $1,683 $1,813 $130

B) 4 points $893 $1,167 $1,442 $1,717 $1,992 $2,267 $2,321 $2,582 $2,843 $3,105 $3,366 $3,627 $261

C) 3 points $1,339 $1,751 $2,164 $2,576 $2,988 $3,400 $3,481 $3,873 $4,265 $4,657 $5,049 $5,441 $391

D) 2 points$1,786 $2,335 $2,885 $3,435 $3,984 $4,534 $4,642 $5,165 $5,687 $6,210 $6,732 $7,255 $522

Above 50% and up to 75% of 60% of the SMI >>or above 150% for households sized 7 or more

Above 75% of 60% of SMI or above 150% of FPG for households sized 7 or more. >>

LIHEAP ONLY - Energy Points for Income by Household SizeNumber of Household Members>>

To determine energy points based upon poverty level

At or below 25% of 60% of SMI or 150% of FPG for households sized 7 or more >>

Above 25% and up to 50% of 60% of SMI >> or above 150% for households sized 7 or more >>

12 For >12

Add

The household income limit for the last 30 days for LIHEAP is 60% of SMI for households sized 6 and under. For households sized 7 and over, the income limit is 150% of FPG - FPL UPDATED FOR SFY 2018

Income limits for LIHEAP households sized 6 and under using 60% of State Median Income

Income limits for LIHEAP households sized 7 and over (using Federal Poverty Guidelines)

6 7 8 9 10 11Number of Household Members>> 1 2 3 4 5

101%-125% of Poverty = Above 100% and at or below 125% of FPG. Threshold for: NHN STCS, CSBG clients aged 59 and under without disabilites. For CSBG/STCS

clients 60+ or persons with disabilities see: 126%-150%

of Poverty below.

126%-150% of Poverty = Above 125% and at or below 150% of FPG. Threshold for: STCS, NHN and CSBG clients aged 60+, persons with disabilities. For LIHEAP

clients see next section, LIHEAP ONLY.

LIHEAP ONLY - Income Thresholds by Household Size

Federal Poverty Guidelines (FPG) - Income thresholds for the last 30 days by percent of FPGNumber of Household Members>>

0%-75% of Poverty = At or under 75% of the FPG, FYI..

76%-100% of Poverty = Above 75% and at or below 100% of FPG. FYI - for reporting and programs with an income limit of 100% of poverty.

Community Action Programs and Services Income Thresholds for Community Action Program Services - Effective July 1, 2017 - June 30, 2018 - Updated 6/2017

Division of Aging and Adult Services ALERT

SFY-18-K3 Technical Assistance

for SFY 2018 Technical Assistance ALERTS are generated periodically to update contractual and/or programmatic requirements and/or clarifications. Please ensure that appropriate Community Action Agency (CAA) staff are aware of this technical assistance. Division of Aging and Adult Services, Community Action Program Services (DAAS/CAPS) – Community Service Block Grant (CSBG) Annual Report Modules 2-4 with Excel Spreadsheets. Attached are copies of the electronic versions (Excel), of the CSBG Annual Report Template, Modules 2-4, and the ROMA Catalogue Template derived from Module 4 of the CSBG Annual Report template provided by the National Association of State Community Services Providers (NASCSP). These modules are included as separate attachments. Attachment #3 ROMA Catalogue, Attachment #4 Module 2, Attachment #5 Module 3, Attachment #6, Module 4. For the Annual Report, the instructions are unchanged from the March 17, 2017 ALERT - Agencies should indicate which targeted NPIs they will track in SFY 2018 using the attached ROMA Catalogue form (attachment #3). The ROMA catalogue is to be submitted to DAAS/CAPS by June 30, 2017. For targeting, DAAS/CAPS suggests agencies utilize a percentage of participants expected to achieve as the target for each NPI used, rather than estimating a hard number. Formulas have been inserted in the forms for this purpose, as well as for determining percentages of participants achieving and targeting accuracy. DAAS/CAPS will assist agencies as needed to complete the ROMA Catalogue. Eligible entities will receive the electronic Excel versions of the CSBG Annual Report and ROMA Catalogue templates in a separate email. Should you have any questions or require additional information, please contact Diana Gravett, Community Action Program Specialist, at [email protected] or (602) 542-6594.

mailto:[email protected]

Agency Name: SFY 18 K3 - Attachment #3

Goal 1: Individuals and Families with low incomes are stable and achieve economic security.

Name of CSBG Eligible Entity Reporting:

Employment

I.) Number of Participants

Served

II.) Target (#) Number of

Participants Expected to

Achieve (Auto calculated if percentage

option used)

III.) Actual Results (#)

IV.) Percentage Achieving Outcome

[III/ I = IV ] (% auto calculated) New

V.) Performance Target Accuracy (III/II = V] (% auto calculated) Figure previously used in

ROMA reports

VI.) Targeting Factor (DES ADDED) Enter the Percentage of

Participants Expected to Achieve Outcome

EXAMPLE: The number of unemployed youth who obtained employment to gain skills or income.(DES ADDED)

45 38 36 80.00% 94.12% 85%

2. The number of unemployed adults who obtained employment (up to a living wage).

0 #DIV/0! #DIV/0!

3. The number of unemployed adults who obtained and maintained employment for at least 90 days (up to a living wage).

0 #DIV/0! #DIV/0!

4. The number of unemployed adults who obtained and maintained employment for at least 180 days (up to a living wage).

0 #DIV/0! #DIV/0!

5. The number of unemployed adults who obtained employment (with a living wage or higher).

0 #DIV/0! #DIV/0!

6. The number of unemployed adults who obtained and maintained employment for at least 90 days (with a living wage or higher).

0 #DIV/0! #DIV/0!

7. The number of unemployed adults who obtained and maintained employment for at least 180 days (with a living wage or higher).

0 #DIV/0! #DIV/0!

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry Form

Employment Indicators






Employment


Served in program(s) (#)

II.) Target (#) III.) Actual Results (#)


[III/ I = IV ] (% auto calculated)

V.) Performance Target Accuracy (III/II = V] (% auto

calculated)

VI.) Targeting Factor (DES ADDED) Input the Percentage of


8. The number of employed participants in a career-advancement related program who entered or transitioned into a position that provided increased income and/or benefits.

0 #DIV/0! #DIV/0!

a. Of the above, the number of employed participants who Increased income from employment through wage or salary amount increase.

0 #DIV/0! #DIV/0!

b. Of the above, the number of employed participants who increased income from employment through hours worked increase.

0 #DIV/0! #DIV/0!

c. Of the above, the number of employed participants who increased benefits related to employment.

0

Other Employment Outcome Indicator


Served








ROMA reports



9. The number of individuals or households ______________.

0 #DIV/0! #DIV/0!

Comments:



Education and Cognitive Development


Served




option used)





ROMA reports


Participants Expected to Achieve

Outcome

1. The number of children (0 to 5) who demonstrated improved emergent literacy skills.

0 #DIV/0! #DIV/0!

2. The number of children (0 to 5) who demonstrated skills for school readiness.

0 #DIV/0! #DIV/0!

3. The number of children and youth who demonstrated improved positive approaches toward learning, including improved attention skills. (auto total).

0 0 0

a. Early Childhood Education (ages 0-5) 0 #DIV/0! #DIV/0!b. 1st grade-8th grade 0 #DIV/0! #DIV/0!c. 9th grade-12th grade 0 #DIV/0! #DIV/0!

4. The number of children and youth who are achieving at basic grade level (academic, social, and other school success skills). (auto total)

0 0 0

a. Early Childhood Education (ages 0-5) 0 #DIV/0! #DIV/0!b. 1st grade-8th grade 0 #DIV/0! #DIV/0!c. 9th grade-12th grade 0 #DIV/0! #DIV/0!

5. The number of parents/caregivers who improved their home environments.

0 #DIV/0! #DIV/0!

6. The number of adults who demonstrated improved basic education.

0 #DIV/0! #DIV/0!

7. The number of individuals who obtained a high school diploma and/or obtained an equivalency certificate or diploma.

0 #DIV/0! #DIV/0!

8. The number of individuals who obtained a recognized credential, certificate, or degree relating to the achievement of educational or vocational skills.

0 #DIV/0! #DIV/0!

9. The number of individuals who obtained an Associate’s degree.

0 #DIV/0! #DIV/0!

10. The number of individuals who obtained a Bachelor’s degree.

0 #DIV/0! #DIV/0!

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry FormGoal 1: Individuals and Families with low incomes are stable and achieve economic security.

Education and Cognitive Development Indicators


Other Education and Cognitive Development Outcome Indicator


Served




option used)





ROMA reports



Outcome

11. The number of individuals or households ______________. 0 #DIV/0! #DIV/0!

Comments:



Income and Asset Building


Served




option used)





ROMA reports

VI.) Targeting Factor (DES

ADDED) Enter the Percentage of Participants

Expected to Achieve

Outcome

EXAMPLE: The number of individuals who achieved and maintained capacity to meet basic needs for 90 days.

395 296 250 63.29% 84.39% 75%

1. The number of individuals who achieved and maintained capacity to meet basic needs for 90 days.

0 #DIV/0! #DIV/0!

2. The number of individuals who achieved and maintained capacity to meet basic needs for 180 days.

0 #DIV/0! #DIV/0!

3. The number of individuals who opened a savings account or IDA.

0 #DIV/0! #DIV/0!

4. The number of individuals who increased their savings.

0 #DIV/0! #DIV/0!

5. The number of individuals who used their savings to purchase an asset.

0 #DIV/0! #DIV/0!

a. Of the above, the number of individuals who purchased a home.

0 #DIV/0! #DIV/0!

6. The number of individuals who improved their credit scores.

0 #DIV/0! #DIV/0!

7. The number of individuals who increased their net worth.

0 #DIV/0! #DIV/0!

8. The number of individuals engaged with the Community Action Agency who report improved financial well-being.

0 #DIV/0! #DIV/0!

Other Income and Asset Building Outcome Indicator


Served



Achieve (Auto calculated if





ROMA reports


ADDED) Enter the Percentage of Participants

Expected to Achieve


0 #DIV/0! #DIV/0!

Comments:


Income and Asset Building Indicators



Housing


Served



Achieve (Auto

calculated if percentage

option used)



[III/ I = IV ] (% auto

calculated) New

V.) Performance

Target Accuracy

(III/II = V] (% auto

calculated) Figure

previously used in ROMA

reports


ADDED) Enter the Percentage of Participants Expected to

Achieve Outcome

1. The number of households experiencing homelessness who obtained safe temporary shelter.

0 #DIV/0! #DIV/0!

2. The number of households who obtained safe and affordable housing.

0 #DIV/0! #DIV/0!

3. The number of households who maintained safe and affordable housing for 90 days.

0 #DIV/0! #DIV/0!

4. The number of households who maintained safe and affordable housing for 180 days.

0 #DIV/0! #DIV/0!

5. The number of households who avoided eviction. 0 #DIV/0! #DIV/0!6. The number of households who avoided foreclosure.

0 #DIV/0! #DIV/0!

7. The number of households who experienced improved health and safety due to improvements within their home (e.g. reduction or elimination of lead, radon, carbon dioxide and/or fire hazards or electrical issues, etc).

0 #DIV/0! #DIV/0!

8. The number of households with improved energy efficiency and/or energy burden reduction in their homes.

0 #DIV/0! #DIV/0!

Other Housing Outcome Indicator


Served



Achieve (Auto

calculated if percentage

option used)



[III/ I = IV ] (% auto

calculated) New

V.) Performance

Target Accuracy

(III/II = V] (% auto

calculated) Figure

previously used in ROMA

reports


ADDED) Enter the Percentage of Participants Expected to

Achieve Outcome


0 #DIV/0! #DIV/0!

Comments:


Housing Indicators



Health and Social/Behavioral Development


Served




option used)





ROMA reports



Outcome

1. The number of individuals who demonstrated increased nutrition skills (e.g. cooking, shopping, and growing food).

0 #DIV/0! #DIV/0!

2. The number of individuals who demonstrated improved physical health and well-being.

0 #DIV/0! #DIV/0!

3. The number of individuals who demonstrated improved mental and behavioral health and well-being.

0 #DIV/0! #DIV/0!

4. The number of individuals who improved skills related to the adult role of parents/ caregivers.

0 #DIV/0! #DIV/0!

5. The number of parents/caregivers who demonstrated increased sensitivity and responsiveness in their interactions with their children.

0 #DIV/0! #DIV/0!

6. The number of seniors (65+) who maintained an independent living situation.

0 #DIV/0! #DIV/0!

7. The number of individuals with disabilities who maintained an independent living situation.

0 #DIV/0! #DIV/0!

8. The number of individuals with chronic illness who maintained an independent living situation.

0 #DIV/0! #DIV/0!

9. The number of individuals with no recidivating event for six months.

0 0 0

a. Youth (ages 14-17) 0 #DIV/0! #DIV/0!b. Adults (ages 18+) 0 #DIV/0! #DIV/0!

Other Health and Social/Behavioral Development Outcome Indicator


Served




option used)





ROMA reports



Outcome


0 #DIV/0! #DIV/0!

Comments:


Health and Social/Behavioral Development Indicators




I.) Number of Participants Served




option used)




New


ROMA reports

VI.) Targeting Factor (DES ADDED) Enter the

Percentage of Participants Expected to Achieve Outcome

1. The number of Community Action program participants who increased skills, knowledge, and abilities to enable them to work with Community Action to improve conditions in the community.

0 #DIV/0! #DIV/0!

a. Of the above, the number of Community Action program participants who improved their leadership skills.

0 #DIV/0! #DIV/0!

b. Of the above, the number of Community Action program participants who improved their social networks.

0 #DIV/0! #DIV/0!

c. Of the above, the number of Community Action program participants who gained other skills, knowledge and abilities to enhance their ability to engage.

0 #DIV/0! #DIV/0!

Other Civic Engagement and Community Involvement Outcome Indicator

I.) Number of Participants Served




option used)




New


ROMA reports

VI.) Targeting Factor (DES ADDED) Enter the

Percentage of Participants Expected to Achieve Outcome


0 #DIV/0! #DIV/0!

Comments:


Civic Engagement and Community Involvement Indicators



Outcomes Across Multiple Domains

I.) Number of

Participants Served




option used)

III.) Actual Results

(#)




ROMA reports



Outcome

1. The number of individuals who achieved one or more outcomes as identified by the National Performance Indicators in various domains.

0 #DIV/0! #DIV/0!

Other Outcome Indicator

I.) Number of

Participants Served




option used)

III.) Actual Results

(#)




ROMA reports



Outcome


0 #DIV/0! #DIV/0!

Comments:

odule 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry FoGoal 1: Individuals and Families with low incomes are stable and achieve economic security.


Agency Name: SFY-18-K3 - Attachment # 4

Domain 7. Services Supporting Multiple Domains are those that span or support

outcomes achieved across multiple domains for families and individuals, such as case

management, transportation, and childcare.

Domain 8: Many of the activities that were associated with Linkages are now

captured in Domain 9 Agency Capacity Building. This narrows the definition of

Linkages, but continues to include community initiatives and information and referral

calls.

Domain 9: Agency Capacity Building expenditures are detailed in Table 2 on this form.

Agency Name:

Reporting Period "X"

July 1-June 30October 1-September 30January 1-December 31

Domain CSBG Funds

1. Employment2. Education and Cognitive Development3. Income, Infrastructure, and Asset Building4. Housing5. Health/Nutrition and Social/Behavioral Development6. Civic Engagement and Community Involvement7. Services Supporting Multiple Domains8. Linkages (e.g. partnerships that support multiple domains)9. Agency Capacity Building (detailed below in Table 2)10. Other (e.g. Emergency management/disaster relief)

Total CSBG Expenditures (auto calculated) $0

Of the CSBG funds reported above, report the total amount used for

Administration*.

*for more information on what qualifies as Administration, refer to IM37

Table 2 - Details on Agency Capacity Building Activities Funded by CSBG:

Module 2, Section A: Local Agency CSBG Expenditures - Data Entry Form

Please specify Other Activities funded by CSBG under Agency Capacity:

1. Please identify which activities were funded by CSBG under Agency Capacity

Section B. Please check all that apply.

Section A: Local Agency CSBG Expenditures Date Entry Form meets the Congressional requirement for

an explanation of the total amount of CSBG funding expended during the reporting period (identified

below) based on categories referenced in the CSBG Act.

Table 1 - CSBG Expenditures:

NOTE: CSBG funding expended during the reporting period should be reported in the domain that best

reflects the services delivered and strategies implemented. Further instructions will be provided but

please keep the following in mind, per domain.

Local Agency Reporting Period:

Community Needs Assessment

Strategic Planning

Data Management

Training and Technical Assistance

Other

June 2016 FRN #1 – CSBG Annual Report

Module 2, Section A Page1 of 1

http://www.acf.hhs.gov/programs/ocs/resource/im-no-37-definition-and-allowability-of-direct-and-administrative-cost


Agency Name: auto populated



July 1-June 30

October 1-September 30auto populated from Module 2,

Section AJanuary 1-December 31

1. Hours of Agency Capacity Building (e.g. training, planning, assessment): Hours

a. Hours of Board Members in capacity building activitiesb. Hours of Agency Staff in capacity building activitiesc. Hours of Volunteer Staff in capacity building activities

Hours

2. Volunteer Hours 0

a. Total number of volunteer hours donated to the agencyi. Of the above, the total number of volunteer hours donated by low-income

individuals

Number

3. Staff Development and Certification Attainment: 0a. Number of Nationally Certified ROMA Trainersb. Number of Nationally Certified ROMA Implementers

c. Number of Certified Community Action Professionals (CCAP)

d. Number of Pathways Reviewerse. Number of Quality Control Inspectors (QCI)f. Number of LEED Risk Certified assessorsg. Number of Building Performance Institute (BPI) certified professionals

h. Number of Classroom Assessment Scoring System (CLASS) certified professionals

i. Number of Certified Housing Quality Standards (HQS) Inspectorsj. Number of American Institute of Certified Planners (AICP)k. Other (Please specify others below):

Unduplicated Number of

Organizations

4. *Partnerships Developed to Expand Agency Capacity 0a. Non-Profitb. Faith Basedc. Local Governmentd. State Government

Module 2, Section B: Local Agency Capacity Building - Data Entry FormSection B: Local Agency Capacity Building Data Entry Form provides detail on agency capacity building funded by CSBG and other

funding sources.




e. Federal Governmentf. For-Profit Business or Corporationg. Consortiums/Collaborationh. Housing Consortiums/Collaborationi. School Districtsj. Institutions of postsecondary education/trainingk. Financial/Banking Institutions

l. Health Service Institutions

m. State wide associations or collaborations

*Only report partnerships here that contribute to the agency's capacity.




Agency Name: auto populated



July 1-June 30

October 1-September 30 auto populated from Module 2, Section A

January 1-December 31

1. Name of Local Agency Reporting:

2. Amount of FY 20XX CSBG allocated to reporting agency 2.

3. Weatherization (DOE) (include oil overcharge $$) 3.

4. Health and Human Services (HHS)a. LIHEAP - Fuel Assistance (include oil overcharge $$) 4a.

b. LIHEAP - Weatherization (include oil overcharge $$) 4b.

c. Head Start 4c.

d. Early Head Start 4d.

e. Older Americans Act 4e.

f. Social Services Block Grant (SSBG) 4f.

g. Medicare/Medicaid 4g.

h. Assets for Independence (AFI) 4h.

i. Temporary Assistance for Needy Families (TANF) 4i.

j. Child Care Development Block Grant (CCDBG) 4j.

k Other HHS Resources

i. CFDA #: 4k.i

ii. CFDA #: 4k.iiiii. CFDA #: 4k.iii

iv. CFDA #: 4k.iv

4k. Total Other HHS Resources (autocalculated) 4k. -$

5. Department of Agriculture (USDA)a. Special Supplemental Nutrition for Women, Infants, and Children (WIC) 5a.

b. All USDA Non-Food programs (e.g. rural development) 5b.

c. All other USDA Food programs 5c.

6. Department of Housing and Urban Development (HUD)a. Community Development Block Grant (CDBG) - Federal, State, and local 6a.

b. Section 8 6b.

c. Section 202 6c.

d. Home Tenant-Based Rental Assistance (HOME TBRA) 6d.

e. HOPE for Homeowners Program (H4H) 6e.

f. Emergency Solutions Grant (ESG) 6f.

g. Continuum of Care (CoC) 6g.

h. All other HUD including homeless programs 6h.

7. Department of Labor (DOL)a. Workforce Innovation and Opportunity Act (WIOA) *previously WIA 7a.

b. Other DOL Employment and Training programs 7b.

c. All other DOL programs 7c.

8. Corporation for National and Community Service (CNCS) programs 8.

9. Federal Emergency Management Agency (FEMA) 9.

10. Department of Transportation 10.

11. Department of Education 11.

Federal Resources Allocated (Other than CSBG)

Module 2, Section C: Local Agency Resources Administered by CSBG Network Report - Data Entry Form

Section C: Local Agency Resources Administered by the CSBG Network data entry form provides data on resources allocated to, administered

through, and generated by the CSBG Network. This report provides valuable information on how CSBG leverages funds from multiple federal, state,

local, and private sources as required in the CSBG Act.




12. Department of Justice 12.

13. Department of Treasury 13.

14. Other Federal Resourcesi. CFDA #: 14.i

ii. CFDA #: 14.ii

iii. CFDA #: 14.iii

iv. CFDA #: 14.iv

14. Total Other Federal Resources (autocalculated) 14. -$

15. Total: Non-CSBG Federal Resources Allocated (autocalculated) -$




16. a. State appropriated funds used for the same purpose as Federal CSBG funds 16a.

b. State Housing and Homeless programs (include housing tax credits) 16b.

c. State Nutrition programs 16c.

d. State Day Care and Early Childhood programs 16d.

e. State Energy programs 16e.

f. State Health programs 16f.

g. State Youth Development programs 16g.

h. State Employment and Training programs 16h.

i. State Head Start programs 16i.

j. State Senior programs 16j.

k. State Transportation programs 16k.

l. State Education programs 16l.

m. State Community, Rural and Economic Development programs 16m.

n. State Family Development programs 16n.

o. Other State Resources

i. 16o.i

ii. 16o.ii

iii. 16o.iii

iv. 16o.iv

16o. Total Other State Resources (autocalculated) 16o. -$

17. Total: State Resources Allocated (autocalculated) 17. -$

18. 18.

19. a. Amount of unrestricted funds appropriated by local government 19a.

b. Amount of restricted funds appropriated by local government 19b.

c. Value of Contract Services 19c.

d. Value of in-kind goods/services received from local government 19d.

20. Total: Local Resources Allocated (autocalculated) 20. -$

21. 21.

22. a. Funds from foundations, corporations, United Way, other nonprofits 22a.

b. Other donated funds 22b.

c. Value of other donated items, food, clothing, furniture, etc. 22c.

d. Value of in-kind services received from businesses 22e.

e. Payments by clients for services 22f.

f. Payments by private entities for goods or services for low income 22g.

clients or communities

23. Total: Private Sector Resources Allocated (autocalculated) 23. -$

24. 24.

25. Total Non-CSBG Resources Allocated: (Federal, State, Local & Private) (autocalculated) 25. -$

State Resources Allocated

If any of these resources were also reported under Item 15, 17, or 20 (Federal, State or Local Resources),

please estimate the amount.

Private Sector Resources Allocated

If any of these resources were also reported under Item 15 or 17 (Federal or State Resources), please

estimate the amount.

Local Resources Allocated

If any of these resources were also reported under Item 15 (Federal Resources), please estimate the

amount.




26. Total Resources in local agency, including CSBG (autocalculated) 26. -$

Note : * All totals are autocalculated




Instructional Notes

Module 3 - Community Level

Module 3, Section A: Community Initiative Status Form

CSBG Eligible Entities will complete the Community Initiative Status Form for the CSBG Eligible Entity identified

initiatives intended to achieve community level outcomes. This form provides a central place to report valuable

information about a single community initiative that started, continued, or ended during the current reporting

period. The information reported on the status form will be selected via a dropdown menu or written as a

narrative. In future reporting periods, CSBG Eligible Entities will update the status form based on the initiative's

progress. Please see additional notes below:

Problem Identification: CSBG Eligible Entities will provide information on how the problem was identified in

the Community Needs Assessment. This will include any data collected.

Ultimate Expected Outcomes: Select the indicator(s) from the Community Level NPIs (full list is found in

Section B) that measures the ultimate expected outcome of the initiative OR enter an "Other Outcome

Indicator".

Issue/CSBG Community Domains: Select the domain(s) category(ies) that best describe the issue addressed

by the initiative. A full list is provided in the Status Form.

Partnership Type: Select the partnership type from the choices provided. For example, a multi-partner

initiative includes the CSBG Eligible Entity and one or more partners.

The first way to report impact is the Counts of Change indicators. These are basic measures that provide the

number of units being measured, e.g. jobs, houses, resources, etc. that have been added (created) or subtracted

(eliminated), and in some cases maintained, in the community the CSBG Eligible Entity has targeted.

The second way to report impact is the Rates of Change indicators. While requiring a bit more information, these

indicators tell the full story of the magnitude of the impact a community initiative (usually involving multiple

organizations) has had in a community.

Module 3, Section B: Community National Performance Indicators (NPIs) - Data Entry Form

To facilitate the reporting, use, and learning from Community NPIs the Annual Report provides two types of

indicators (Counts of Change and Rates of Change). Based on the community-level work in which the CSBG

Eligible Entity is engaged, select the appropriate NPIs in either section. All the NPIs are optional and a category of

“other” exists for a CSBG Eligible Entity to create its own indicator if none of those provided captures what the

CSBG Eligible Entity is trying to achieve.

October 2016FRN #2 –CSBG Annual Report

Module 3, Instructional Notes


Instructional Notes

Module 3 - Community Level

Note, outcomes will only be reported once a community initiative has been reached or when progress has been

made toward the ultimate expected outcome. If progress has not been made, there is a place to identify this in

the Community Initiative Status Form.

Module 3, Section C: Community Strategies List

CSBG Eligible Entities will use the Community Strategies field provided in the Community Initiative Status form to

identify relevant strategies community level initiative. A complete listing of the Community Strategies is found in

Section C. The Community Strategies List provides a basic identification of strategies, arranged by Domain and by

topic area. The list cannot be all-inclusive, as such an “other” category is included. This standardized list will aid

in local and state analysis of the relationship between community-level strategies and outcomes.

Example 1: If you are measuring a percent increase in shelter beds, you would provide the following

information:

II.) Baseline existing starting point used for comparisons (#): Total Number of shelter beds (last year)

III.) Target (#): Targeted Number of shelter beds

V.) Actual Results (#): Actual number of shelter beds for the year

Assistance with these types of calculations can either be obtained locally or from the national partners.

In the Rates of Change section, the measures call for reporting the “percent change”—the increase or decrease of

something from one year to the next. Please see the examples below.

The calculation for a percent increase or decrease for the community NPI rates of change is auto calculated in

column VI (actual percent change from baseline). The same logic applies when reporting a percent decrease.

Example 2: If you are measuring a percent increase in the high school graduation rate in the identified

community (in this case one school district), you would provide the following information:

II.) Baseline existing starting point used for comparisons (#): High School Graduation Rate (last year)

III.) Target (#): Targeted High School Graduation Rate

V.) Actual Results (#): Actual High School Graduation Rate (at the end of the initiative)




1. Initiative Name

2. Initiative Year

3. Problem Identification

4. Goal/Agenda

5. Issue/CSBG Community

Domains

6. Ultimate Expected Outcome

7. Identified Community

8. Expected Duration

9. Partnership Type

10. Partners

11. Strategy(ies)

12. Progress on

Outcomes/Indicators

13. Impact of Outcomes

14. Outcomes/Indicators to

Report

15. Final Status

16. Lessons Learned

Module 3, Section A: Community Initiative Status Form


1-7+ years

Narrative

(Provide a narrative on the scope of the problem)

Narrative

(Provide a narrative on the goal/agenda)

Use the dropdown menu to select the response where appropriate.

Employment; Education and Cognitive Development; Income, Infrastructure,

and Asset Building; Housing; Health and Social/Behavioral Development; or Civic

Engagement and Community Involvement

Community Level National Performance Indicators (NPIs)

(Reference the Community NPIs listed in Section B)

Neighborhood, City, School District, County, Service Area, State, Region, or Other

Narrative

(Provide additional information on the scope of the impact of these outcomes.

e.g. If an initiative created a health clinic, please describe how many individuals

and families are expected to be impacted.)

Community Level National Performance Indicators (NPIs)

(Reference the Community NPIs listed in Section B)

Initiative Active, Initiative Ended Early, Initiative Ended as Planned, Completed

Still Delivering Value

Narrative

Narrative

(Provide the range in years, e.g. 1-3 years)

Independent CAA Initiative, CAA is the core organizer of multi-partner Initiative,

or CAA is one of multiple active investors and partners

Narrative

(Provide a narrative on the key 1-3 partners)

Select from the Community Level Strategies listed in Section C

No Outcomes to Report, Interim Outcomes, Final Outcomes





I.) Identified

Community

(auto-populated)

II.) Target

(#)

III.) Actual

Results

(#)

IV.) Performance

target accuracy

(% auto

calculated)

I.) Identified

Community(auto-populated)

II.) Target (#)

III.) Actual

Results(#)

IV.) Performance

target accuracy (% auto calculated)

I.) Identified


II.) Baseline existing starting

point used for

comparisons

(#)

III.)

Target (#)

IV.) Expected %

change from

baseline (Target % auto

calculated)

V.) Actual Results(#)

VI.) Actual %

change from

baseline (% auto

calculated)

VII.)

Performance

target accuracy(% auto calculated)

I.) Identified



point used for

comparisons

(#)

III.)

Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.)

Performance


General comments:


Goal 2: Communities where people with low incomes live are healthy and offer economic opportunity.


5. Number of jobs created in the identified community with a benefit package.

Counts of Change for Employment Indicators

Counts

of

Change

1. Number of jobs created to increase opportunities for people with low incomes in the identified

community.

2. Number of job opportunities maintained in the identified community.

3. Number of “living wage ” jobs created in the identified community*.

4. Number of “living wage” jobs maintained in the identified community*.

*When reporting on indicators related to living wage, agencies can provide their own definition or select from national or locally-defined models. Please indicate the living wage definition used in the General Comment box.

Other

Rates of

Change

Rates of Change for Employment Indicators

1. Percent decrease of the unemployment rate.

2. Percent decrease of the youth unemployment rate.

3. Percent decrease of the underemployment rate.

Other Counts of Change for Employment Indicators - Please specify below.

Other Rates of Change for Employment Indicators - Please specify below.

Other

Counts of

Change

Rates of

Change





I.) Identified


II.) Target (#)

III.) Actual

Results(#)

IV.) Performance


I.) Identified


II.) Target (#)

III.) Actual

Results(#)

IV.) Performance


Other

Counts of

Change

Other Counts of Change for Education and Cognitive Development Indicators - Please specify below.




Counts of Change for Education and Cognitive Development Indicators

1. Number of accessible and affordable early childhood or pre-school education assets or resources added to the

identified community.

2. Number of accredited or licensed affordable child care facilities added in the identified community.

3. Number of new Early Childhood Screenings offered to children (ages 0-5) of families with low-incomes in the

identified community.

5. Number of accessible and affordable post secondary education assets or resources added for newly graduating

youth in the identified community. (e.g. college tuition, scholarships, vocational training, etc.)

4. Number of accessible and affordable education assets or resources added for school age children in the identified

community. (e.g., academic, enrichment activities, before/after school care, summer programs)

6. Number of accessible and affordable basic or secondary education assets or resources added for adults in the

identified community. (e.g. literacy, ESL, ABE/GED, etc.)

Counts

of

Change







I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


I.) Identified

Community(auto populated)


point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


General comments:

Other

Rates of

Change

Other Rates of Change for Education and Cognitive Development

Indicators- Please specify below.

2. Percent increase of children in the identified community at (or

above) the basic reading level.

3. Percent increase of children in the identified community at (or

above) the basic math level.

4. Percent increase in high school (or high school equivalency)

graduation rate in the identified community.

Rates of

Change

Rates of Change for Education and Cognitive Development

Indicators

1. Percent increase of children in the identified community who

are kindergarten ready.

5. Percent increase of the rate of youth in the identified

community who attend post-secondary education.

8. Percent increase of adults in the identified community who

graduate from post-secondary education.

9. Percent increase in the adult literacy rate in the identified

community .

7. Percent increase of adults in the identified community who

attend post-secondary education.

6. Percent increase of the rate of youth in the identified

community who graduate from post-secondary education.





I.) Identified


II.) Target (#)

III.) Actual

Results(#)

IV.) Performance


a.

b.

c.

d.

e.

f.

a.

b.

c.

d.

e.

f.

I.) Identified


II.) Target (#)

III.) Actual

Results(#)

IV.) Performance




Infrastructure and Asset Building Indicators

Transportation

Technological/ Communications (e.g.

broadband)

2. Number of existing assets/resources made accessible to the identified community:

Commercial

Other Counts of Change for Infrastructure and

Asset Building Indicators - Please specify below.

Commercial

Counts of Change for Infrastructure and Asset

Building Indicators

1. Number of new accessible assets/resources created in the identified community:

Counts

of

Change

Financial

Financial

Other Public Assets/Physical Improvements

Recreational (e.g. parks, gardens, libraries)

Technological/ Communications (e.g.

broadband)

Transportation

Recreational (e.g. parks, gardens, libraries)

Other Public Assets/Physical Improvements

Other

Counts of

Change






Infrastructure and Asset Building Indicators

I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)

V.) Actual

Results(#)

VI.) Actual %

change from

baseline (% auto calculated)

VII.)

Performance

target

accuracy(% auto

calculated)

I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)

V.) Actual

Results(#)

VI.) Actual %

change from

baseline (% auto calculated)

VII.)

Performance

target

accuracy(% auto

calculated)

General comments:

5. Percent increase of transportation services in

the identified community.

Other

Rates of

Change

Rates of

Change

Other Rates of Change for Infrastructure and

Asset Building Indicators- Please specify below.

Rates of Change for Infrastructure and Asset

Building Indicators

1. Percent decrease of abandoned or neglected

buildings in the identified community.

2. Percent decrease in emergency response time

measured in minutes in the identified community.

(EMT, Police, Fire, etc.).

3. Percent decrease of predatory lenders and/or

lending practices in the identified community.

4. Percent decrease of environmental threats to

households (toxic soil, radon, lead, air quality,

quality of drinking water, etc.) in the identified

community.





I.) Identified


II.) Target (#)

III.) Actual

Results(#)

IV.) Performance


I.) Identified


II.) Target (#)

III.) Actual

Results(#)

IV.) Performance


I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


Rates of

Change

Rates of Change for Housing Indicators

1. Percent decrease in the rate of homelessness in the identified

community.

2. Percent decrease in the foreclosure rate in the identified

community.3. Percent increase in the rate of home ownership of people with

low incomes in the identified community.

5. Percent increase of shelter beds in the identified community.

4. Percent increase of affordable housing in the identified

community.

4. Number of shelter beds maintained in the identified community.

Other

Counts of

Change

Other Counts of Change for Housing Indicators- Please specify below.



Housing Indicators

Counts of Change for Housing Indicators

1. Number of safe and affordable housing units developed in the identified community (e.g. built or set aside units

for people with low incomes).

2. Number of safe and affordable housing units maintained and/or improved through WAP or other rehabilitation

efforts in the identified community.

3. Number of shelter beds created in the identified community.

Counts

of

Change






Housing Indicators

I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


General comments:

Other

Rates of

Change

Other Rates of Change for Housing Indicators- Please specify below.





I.) Identified


II.) Target (#)

III.) Actual

Results(#)

IV.) Performance


I.) Identified


II.) Target (#)

III.) Actual

Results(#)

IV.) Performance


I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


Counts

of

Change

5. Number of activities designed to improve police and community relations within the identified community.

Rates of Change for Physical Health, Wellbeing, and

Development Indicators

1. Percent decrease in infant mortality rate in the identified community.

2. Percent decrease in childhood obesity rate in the identified

community.

3. Percent decrease in adult obesity rate in the identified community.

4. Percent increase in child immunization rate in the identified

community.

5. Percent decrease in uninsured families in the identified community.



Health and Social/Behavioral Indicators

Counts of Change for Health and Social/Behavioral Indicators

1. Number of accessible and affordable physical health assets or resources created in the identified community.

2. Number of accessible and affordable behavioral and mental health assets or resources created in the identified community.

3. Number of public safety assets and resources created in the identified community.

4. Number of accessible and affordable healthy food resources created in the identified community.

Other

Counts of

Change

Other Counts of Change for Health and Social/Behavioral Indicators- Please specify below.

Rates of

Change







I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


Rates of

Change

7. Percent decrease in the elder abuse rate in the identified community.

Rates of

Change

Rates of Change for Behavioral and Mental health, Emotional

Wellbeing, and Development Indicators

1. Percent decrease in the teen pregnancy rate in the identified

community.

2. Percent decrease in unplanned pregnancies in the identified

community.

3. Percent decrease in substance abuse rate in the identified

community.(e.g. cigarettes, prescription drugs, narcotics, alcohol).

4. Percent decrease in domestic violence rate in the identified

community.

8. Percent decrease in the elder neglect rate in the identified

community.

Rates of Change for Public Safety Indicators

1. Percent decrease in recidivism rate in the identified community.

2. Percent decrease in non-violent crime rate in the identified

community.

3. Percent decrease in violent crime rate in the identified community.

4. Percent decrease in teens involved with the juvenile court system in

the identified community.

6. Percent decrease in the child neglect rate in the identified

community.

5. Percent decrease in the child abuse rate in the identified community.







I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


General comments:

Other Rates of Change for Health and Social/Behavioral

Indicators- Please specify below.

Other

Rates of

Change





I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


General comments:

Other

Rates of

Change

Other Rates of Change for Civic Engagement and Community

Involvement Indicators- Please specify below.




Rates of

Change

Rates of Change for Civic Engagement and Community

Involvement Indicators

1. Percent increase of donated time to support the CSBG Eligible Entity's

delivery of services and/or implementation of strategies to address

conditions of poverty in the identified community.

2. Percent increase of donated resources to support the CSBG Eligible

Entity's delivery of services and/or implementation of strategies to

address conditions of poverty in the identified community.

3. Percent increase of people participating in public hearings, policy

forums, community planning, or other advisory boards related to the

CSBG Eligible Entity's delivery of service and/or implementation of

strategies to address conditions of poverty in the identified community.





I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


I.) Identified



point used for

comparisons

(#)

III.) Target (#)

IV.) Expected %

change from


calculated)


VI.) Actual %

change from

baseline (% auto

calculated)

VII.) Performance


General comments:

Other

Rates of

Change

Other Rates of Change for Civic Engagement and Community

Involvement Indicators- Please specify below.


Goal 3: People with low-incomes are engaged and active in building opportunities in communities.


Rates of

Change

Rates of Change for Civic Engagement and Community

Involvement Indicators

1. Percent increase of people with low incomes who support the CSBG

Eligible Entity's delivery of service and/or implementation of strategies

to address conditions of poverty in the identified community.

2. Percent increase of people with low incomes who acquire and

maintain leadership roles with the CSBG Eligible Entity or other

organizations within the identified community.





Employment Strategies

Minimum/Living Wage Campaign

Job Creation/Employment Generation

Job Fairs

Earned Income Tax Credit (EITC) Promotion

Commercial Space Development

Employer Education

Employment Policy Changes

Employment Legislative Changes

Other Employment Strategy: (please specify)

Education and Cognitive Development Strategies

Preschool for All Campaign

Charter School Development

After School Enrichment Activities Promotion

Pre K-College/Community College Support

Children’s Trust Fund Creation

Scholarship Creation

Child Tax Credit (CTC) Promotion

Adoption Child Care Quality Rating

Adult Education Establishment

Education and Cognitive Development Policy Changes

Education and Cognitive Development Legislative Changes

Other Education and Cognitive Development Strategy: (please specify)

Infrastructure and Asset Building Strategies

Cultural Asset Creation

Police/Community Relations Campaign

Neighborhood Safety Watch Programs

Anti-Predatory Lending Campaign

Asset Building and Savings Promotion

Develop/Build/Rehab Spaces

Maintain or Host Income Tax Preparation Sites

Community-Wide Data Collection Systems Development

Local 211 or Resource/Referral System Development

Water/Sewer System Development

Community Financial Institution Creation

Infrastructure Planning Coalition

Park or Recreation Creation and Maintenance

Rehabilitation/Weatherization of Housing Stock

Community Center/Community Facility Establishment

Asset Limit Barriers for Benefits Policy Changes

Infrastructure and Asset Building Policy Changes

Infrastructure and Asset Building Legislative Changes

Other Infrastructure and Asset Building Strategy: (please specify)





Housing Strategies

End Chronic Homelessness Campaign

New Affordable Single Unit Housing Creation

New Affordable Multi- Unit Housing Creation (Single Resident Occupancy (SRO), temporary housing, transitional housing)

Tenants’ Rights Campaign

New Shelters Creation (including day shelters and domestic violence shelters)

Housing or Land Trust Creation

Building Codes Campaign

Housing Policy Changes

Housing Legislative Changes

Other Housing Strategy: (please specify)

Health and Social/Behavioral Development Strategies

Health Specific Campaign

Farmers Market or Community Garden Development

Grocery Store Development

Gun Safety/Control Campaign

Healthy Food Campaign

Nutrition Education Collaborative

Food Bank Development

Domestic Violence Court Development

Drug Court Development

Alternative Energy Source Development

Develop or Maintain a Health Clinic

Health and Social/Behavioral Development Policy Changes

Health and Social/Behavioral Development Legislative Changes

Other Health and Social/Behavioral Development Strategy: (please specify)

Community Support Strategies

Off-Hours (Non-Traditional Hours) Child Care Development

Transportation System Development

Transportation Services Coordination and Support

Community Support Policy Changes

Community Support Legislative Changes

Other Community Support Strategy: (please specify)

Emergency Management Strategies

State or Local Emergency Management Board Enhancement

Community wide Emergency Disaster Relief Service Creation

Disaster Preparation Planning

Emergency Management Policy Changes

Emergency Management Legislative Changes

Other Emergency Management Strategy: (please specify)





Civic Engagement and Community Involvement Strategies- Goal 2

Development of Health and Social Service Provider Partnerships

Recruiting and Coordinating Community Volunteers

Poverty Simulations

Attract Capital Investments

Build/Support Increased Equity

Equity Awareness Campaign

Coordinated Community-wide Needs Assessment

Civic Engagement and Community Involvement in Advocacy Efforts

Civic Engagement Policy Changes

Civic Engagement Legislative Changes

Other Civic Engagement and Community Involvement Strategy: (please specify)

Civic Engagement and Community Involvement Strategies — Goal 3

Empowerment of Individuals/Families with Low-Incomes

Campaign to Ensure Individuals with Low-Incomes are Represented on Local Governing Bodies

Social Capital Building Campaign for Individuals/Families with Low-Incomes

Campaign for Volunteer Placement and Coordination

Civic Engagement Policy Changes

Civic Engagement Legislative Changes

Other Civic Engagement and Community Involvement Strategy: (please specify)



Agency Name: SFY-18-K3 - Attachment #6


Employment

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving

Outcome [III/ I = IV ] (%

auto calculated)

New

V.) Performance

Target Accuracy (III/II = V] (% auto

calculated) Figure

previously used

in ROMA reports

VI.) Targeting Factor

(DES ADDED) Enter

the Percentage of

Participants

Expected to Achieve

Outcome

1. The number of unemployed youth who

obtained employment to gain skills or

income. EXAMPLE (DES ADDED)

45 38 36 80.00% 94.12% 85%

1. The number of unemployed youth who

obtained employment to gain skills or

income.

0 #DIV/0! #DIV/0!

2. The number of unemployed adults who

obtained employment (up to a living wage).0 #DIV/0! #DIV/0!


obtained and maintained employment for at

least 90 days

(up to a living wage).

0 #DIV/0! #DIV/0!



least 180 days

(up to a living wage).

0 #DIV/0! #DIV/0!


obtained employment (with a living wage or

higher).

0 #DIV/0! #DIV/0!



least 90 days

(with a living wage or higher).

0 #DIV/0! #DIV/0!



least 180 days

(with a living wage or higher).

0 #DIV/0! #DIV/0!

Employment

I.) Number of

Participants

Served in program(s) (#)

II.) Target (#) III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

V.) Performance


calculated)


(DES ADDED) Input

the Percentage of

Participants

Expected to Achieve

Outcome

8. The number of employed participants in a

career-advancement related program who

entered or transitioned into a position that

provided increased income and/or benefits.

0 #DIV/0! #DIV/0!

a. Of the above, the number of

employed participants who Increased

income from employment through wage

or salary amount increase.

0 #DIV/0! #DIV/0!




October 2016FRN #2 – CSBG Annual Report

Module 4, Section A: Individual and Family NPIs - Employment






b. Of the above, the number of

employed participants who increased

income from employment through

hours worked increase.

0 #DIV/0! #DIV/0!

c. Of the above, the number of

employed participants who increased

benefits related to employment.

0

Other Employment Outcome Indicator

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports


(DES ADDED) Enter

the Percentage of

Participants

Expected to Achieve

Outcome

9. The number of individuals or households

______________.0 #DIV/0! #DIV/0!

Comments:





Education and Cognitive Development

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports

1. The number of children (0 to 5) who demonstrated

improved emergent literacy skills.0 #DIV/0! #DIV/0!

2. The number of children (0 to 5) who demonstrated

skills for school readiness. 0 #DIV/0! #DIV/0!

3. The number of children and youth who

demonstrated improved positive approaches toward

learning, including improved attention skills. (auto

total).

0 0 0

a. Early Childhood Education (ages 0-5) 0 #DIV/0! #DIV/0!

b. 1st grade-8th grade 0 #DIV/0! #DIV/0!

c. 9th grade-12th grade 0 #DIV/0! #DIV/0!

4. The number of children and youth who are achieving

at basic grade level (academic, social, and other school

success skills). (auto total)

0 0 0

a. Early Childhood Education (ages 0-5) 0 #DIV/0! #DIV/0!

b. 1st grade-8th grade 0 #DIV/0! #DIV/0!

c. 9th grade-12th grade 0 #DIV/0! #DIV/0!

5. The number of parents/caregivers who improved

their home environments. 0 #DIV/0! #DIV/0!

6. The number of adults who demonstrated improved

basic education.0 #DIV/0! #DIV/0!

7. The number of individuals who obtained a high

school diploma and/or obtained an equivalency

certificate or diploma.

0 #DIV/0! #DIV/0!

8. The number of individuals who obtained a

recognized credential, certificate, or degree relating to

the achievement of educational or vocational skills.

0 #DIV/0! #DIV/0!

9. The number of individuals who obtained an

Associate’s degree.0 #DIV/0! #DIV/0!

10. The number of individuals who obtained a

Bachelor’s degree.0 #DIV/0! #DIV/0!

Other Education and Cognitive Development

Outcome Indicator

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports


______________.0 #DIV/0! #DIV/0!







Comments:




VI.) Targeting

Factor (DES

ADDED) Enter the

Percentage of

Participants

Expected to

Achieve Outcome

VI.) Targeting

Factor (DES

ADDED) Enter the

Percentage of

Participants

Expected to

Achieve Outcome





Income and Asset Building

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports

1. The number of individuals who achieved and

maintained capacity to meet basic needs for 90

days.

0 #DIV/0! #DIV/0!

2. The number of individuals who achieved and

maintained capacity to meet basic needs for 180

days.

0 #DIV/0! #DIV/0!

3. The number of individuals who opened a savings

account or IDA.0 #DIV/0! #DIV/0!

4. The number of individuals who increased their

savings.0 #DIV/0! #DIV/0!

5. The number of individuals who used their

savings to purchase an asset.0 #DIV/0! #DIV/0!

a. Of the above, the number of individuals who

purchased a home.0 #DIV/0! #DIV/0!

6. The number of individuals who improved their

credit scores. 0 #DIV/0! #DIV/0!

7. The number of individuals who increased their

net worth. 0 #DIV/0! #DIV/0!

8. The number of individuals engaged with the

Community Action Agency who report improved

financial well-being.

0 #DIV/0! #DIV/0!

Other Income and Asset Building Outcome

Indicator

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports


______________.0 #DIV/0! #DIV/0!

Comments:


Income and Asset Building Indicators





VI.) Targeting

Factor (DES

ADDED) Enter the

Percentage of

Participants

Expected to

Achieve Outcome

VI.) Targeting

Factor (DES

ADDED) Enter the

Percentage of

Participants

Expected to

Achieve Outcome





Housing

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports

1. The number of households experiencing

homelessness who obtained safe temporary

shelter.

0 #DIV/0! #DIV/0!

2. The number of households who obtained safe

and affordable housing.0 #DIV/0! #DIV/0!

3. The number of households who maintained

safe and affordable housing for 90 days.0 #DIV/0! #DIV/0!

4. The number of households who maintained

safe and affordable housing for 180 days. 0 #DIV/0! #DIV/0!

5. The number of households who avoided

eviction.0 #DIV/0! #DIV/0!

6. The number of households who avoided

foreclosure.0 #DIV/0! #DIV/0!

7. The number of households who experienced

improved health and safety due to

improvements within their home (e.g. reduction

or elimination of lead, radon, carbon dioxide

and/or fire hazards or electrical issues, etc).

0 #DIV/0! #DIV/0!

8. The number of households with improved

energy efficiency and/or energy burden

reduction in their homes.

0 #DIV/0! #DIV/0!

Other Housing Outcome Indicator

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports


______________.0 #DIV/0! #DIV/0!

Comments:

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data Entry


Housing Indicators




VI.) Targeting

Factor (DES

ADDED) Enter the

Percentage of

Participants

Expected to

Achieve Outcome

VI.) Targeting

Factor (DES

ADDED) Enter the

Percentage of

Participants

Expected to

Achieve Outcome





Health and Social/Behavioral

Development

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports

VI.) Targeting

Factor (DES ADDED)

Enter the

Percentage of

Participants

Expected to

Achieve Outcome

1. The number of individuals who

demonstrated increased nutrition skills

(e.g. cooking, shopping, and growing

food).

0 #DIV/0! #DIV/0!


demonstrated improved physical health

and well-being.

0 #DIV/0! #DIV/0!


demonstrated improved mental and

behavioral health and well-being.

0 #DIV/0! #DIV/0!


improved skills related to the adult role of

parents/ caregivers.

0 #DIV/0! #DIV/0!

5. The number of parents/caregivers who

demonstrated increased sensitivity and

responsiveness in their interactions with

their children.

0 #DIV/0! #DIV/0!

6. The number of seniors (65+) who

maintained an independent living

situation.

0 #DIV/0! #DIV/0!

7. The number of individuals with

disabilities who maintained an

independent living situation.

0 #DIV/0! #DIV/0!

8. The number of individuals with chronic

illness who maintained an independent

living situation.

0 #DIV/0! #DIV/0!

9. The number of individuals with no

recidivating event for six months.0 0 0

a. Youth (ages 14-17) 0 #DIV/0! #DIV/0!

b. Adults (ages 18+) 0 #DIV/0! #DIV/0!











Other Health and Social/Behavioral

Development Outcome Indicator

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports

VI.) Targeting

Factor (DES ADDED)

Enter the

Percentage of

Participants

Expected to

Achieve Outcome

10. The number of individuals or

households ______________.0 #DIV/0! #DIV/0!

Comments:






I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports

1. The number of Community Action program

participants who increased skills, knowledge, and

abilities to enable them to work with Community

Action to improve conditions in the community.

a. Of the above, the number of Community

Action program participants who improved

their leadership skills.

b. Of the above, the number of Community

Action program participants who improved

their social networks.

0 #DIV/0! #DIV/0!

c. Of the above, the number of Community

Action program participants who gained other

skills, knowledge and abilities to enhance their

ability to engage.

0 #DIV/0! #DIV/0!

Other Civic Engagement and Community

Involvement Outcome Indicator

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports


______________.0 #DIV/0! #DIV/0!

Comments:







VI.) Targeting

Factor (DES ADDED)

Enter the

Percentage of

Participants

Expected to

Achieve Outcome

VI.) Targeting

Factor (DES ADDED)

Enter the

Percentage of

Participants

Expected to

Achieve Outcome






I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports

1. The number of individuals who achieved one or

more outcomes as identified by the National

Performance Indicators in various domains.

0 #DIV/0! #DIV/0!

Other Outcome Indicator

I.) Number of

Participants

Served

II.) Target (#)

Number of

Participants

Expected to

Achieve (Auto

calculated if

percentage

option used)

III.) Actual

Results (#)

IV.) Percentage

Achieving


auto calculated)

New

V.) Performance


calculated) Figure

previously used

in ROMA reports


______________.0 #DIV/0! #DIV/0!

Comments:

Module 4, Section A: Individual and Family National Performance Indicators (NPIs) - Data

Goal 1: Individuals and Families with low incomes are stable and achieve economic security.Outcomes Across Multiple Domains





(DES ADDED) Enter

the Percentage of

Participants Expected

to Achieve Outcome


(DES ADDED) Enter

the Percentage of

Participants Expected

to Achieve Outcome





Employment Services Unduplicated Number of

Individuals Served

Vocational Training

On-the-Job and other Work Experience

Youth Summer Work Placements

Apprenticeship/Internship

Self-Employment Skills Training

Job Readiness Training

Workshops

Coaching

Coaching

Resume Development

Interview Skills Training

Job Referrals

Job Placements

Pre-employment physicals, background checks, etc.

Coaching

Interactions with employers

Employment Supplies

Module 4, Section B: Individual and Family Services - Data Entry Form

Career Counseling

Job Search

Post Employment Supports

Employment Supplies

Skills Training and Opportunities for Experience

Goal 1: Individuals and Families with low-incomes are stable and achieve economic security.

Employment Services





Education and Cognitive Development Services Unduplicated Number of

Individuals Served

Early Head Start

Head Start

Other Early-Childhood (0-5 yr. old) Education

K-12 Education

K-12 Support Services

Financial Literacy Education

Literacy/English Language Education

College-Readiness Preparation/Support

Other Post Secondary Preparation

Other Post Secondary Support

School Supplies

Before and After School Activities

Summer Youth Recreational Activities

Summer Education Programs

Behavior Improvement Programs (attitude, self-

esteem, Dress-for-Success, etc.)

Mentoring

Leadership Training

Adult Literacy Classes

English Language Classes

Basic Education Classes

High School Equivalency Classes

Leadership Training

Parenting Supports (may be a part of the early

childhood programs identified above)

Applied Technology Classes

Post-Secondary Education Preparation

Financial Literacy Education

College applications, text books, computers, etc.

Scholarships

Home Visits

Child/Young Adult Education Programs



Education and Cognitive Development Services

Home Visits

School Supplies

Extra-curricular Programs

Adult Education Programs

Post-Secondary Education Supports

Financial Aid Assistance





Income and Asset Building Services Unduplicated Number of

Individuals Served

Financial Capability Skills Training

Financial Coaching/Counseling

Financial Management Programs (including budgeting, credit

management, credit repair, credit counseling, etc.)

First-time Homebuyer Counseling

Foreclosure Prevention Counseling

Small Business Start-Up and Development Counseling

Sessions/Classes

Child Support Payments

Health Insurance

Social Security/SSI Payments

Veteran's Benefits

TANF Benefits

SNAP Benefits

Saving Accounts/IDAs and other asset building accounts

Other financial products (IRA accounts, MyRA, other

retirement accounts, etc.)

VITA, EITC, or Other Tax Preparation programs

Micro-loans

Business incubator/business development loans

Benefit Coordination and Advocacy

Asset Building

Loans And Grants

Training and Counseling Services



Income and Asset Building Services





Housing Services Unduplicated Number of

Individuals Served

Financial Capability Skill Training

Financial Coaching/Counseling

Rent Payments (includes Emergency Rent Payments)

Deposit Payments

Mortgage Payments (includes Emergency Mortgage Payments)

Eviction Counseling

Landlord/Tenant Mediations

Landlord/Tenant Rights Education

Utility Payments (LIHEAP-includes Emergency Utility Payments)

Utility Deposits

Utility Arrears Payments

Level Billing Assistance

Temporary Housing Placement (includes Emergency Shelters)

Transitional Housing Placements

Permanent Housing Placements

Rental Counseling

Home Repairs (e.g. structural, appliance, heating systems. etc.)

(Including Emergency Home Repairs)

Independent-living Home Improvements (e.g. ramps, tub and

shower grab bars, handicap accessible modifications, etc.)

Healthy Homes Services(e.g. reduction or elimination of lead,

radon, carbon dioxide and/or fire hazards or electrical issues,

etc.)

Energy Efficiency Improvements (e.g. insullation, air sealing,

furnace repair, etc.)

Housing Placement/Rapid Re-housing

Housing Maintenance & Improvements

Weatherization Services

Housing Payment Assistance



Housing Services

Eviction Prevention Services

Utility Payment Assistance





Health and Social/Behavioral Development Services Unduplicated Number of

Individuals Served

Immunizations

Physicals

Developmental Delay Screening

Vision Screening

Prescription Payments

Doctor Visit Payments

Maternal/Child Health

Nursing Care Sessions

In-Home Affordable Seniors/Disabled Care Sessions

(Nursing, Chores, Personal Care Services)

Health Insurance Options Counseling

Coaching Sessions

Family Planning Classes

Contraceptives

STI/HIV Prevention Counseling Sessions

STI/HIV Screenings

Wellness Classes (stress reduction, medication management,

mindfulness, etc.)

Exercise/Fitness

Detoxification Sessions

Substance Abuse Screenings

Substance Abuse Counseling

Mental Health Assessments

Mental Health Counseling

Crisis Response/Call-In Responses

Domestic Violence Programs

Substance Abuse Support Group Meetings

Domestic Violence Support Group Meetings

Mental Health Support Group Meeting

Reproductive Health Services

Wellness Education

Mental/Behavioral Health

Support Groups

Health Services, Screening and Assessments











Health and Social/Behavioral Development Services (Cont'd.) Unduplicated Number of

Individuals Served

Adult Dental Screening/Exams

Adult Dental Services (including Emergency Dental Procedures)

Child Dental Screenings/Exams

Child Dental Services (including Emergency Dental Procedures)

Skills Classes (Gardening, Cooking, Nutrition)

Community Gardening Activities

Incentives (e.g. gift card for food preparation, rewards for

participation, etc.)

Prepared Meals

Food Distribution (Food Bags/Boxes, Food Share Program, Bags of

Groceries)

Family Mentoring Sessions

Life Skills Coaching Sessions

Parenting Classes

Kits/boxes

Hygiene Facility Utilizations (e.g. showers, toilets, sinks)

Nutrition and Food/Meals

Family Skills Development

Emergency Hygiene Assistance

Dental Services, Screenings and Exams





Services Supporting Multiple Domains Unduplicated Number of

Individuals Served

Case Management

Eligibility Determinations

Referrals

Transportation Services (e.g. bus passes, bus transport, support for auto

purchase or repair; including emergency services)

Child Care subsidies

Child Care payments

Day Centers

Birth Certificate

Social Security Card

Driver's License

Criminal Record Expungements

Immigration Support Services (relocation, food, clothing)

Legal Assistance

Emergency Clothing Assistance

Mediation/Customer Advocacy Interventions

Re-Entry Services

Immigration Support Services

Legal Assistance (includes emergency legal assistance)

Emergency Clothing Assistance

Mediation/Customer Advocacy Interventions (debt forgiveness, negotiations or issues with

landlords, coordinating with other services or government)

Referrals

Childcare

Eldercare

Identification Documents

Transportation Services


Services Supporting Multiple Domains


Case Management

Eligibility Determinations





Civic Engagement and Community Involvement Services Unduplicated Number of

Individuals Served

Voter Education and Access

Leadership Training

Tri-partite Board Membership

Citizenship Classes

Getting Ahead Classes

Volunteer Training



Civic Engagement and Community Involvement





A. Total unduplicated number of all INDIVIDUALS about whom one or more characteristics were obtained:

B. Total unduplicated number of all HOUSEHOLDS about whom one or more characteristics were obtained:

C. INDIVIDUAL LEVEL CHARACTERISTICS

1. Gender Number of Individuals 6. Ethnicity/Race Number of Individuals

a. Male I. Ethnicityb. Female a. Hispanic, Latino or Spanish Originsc. Other b. Not Hispanic, Latino or Spanish Originsd. Unknown/not reported c. Unknown/not reported

TOTAL (auto calculated) 0 TOTAL (auto calculated) 0

2. Age Number of Individuals II. Race

a. 0-5 a. American Indian or Alaska Native

b. 6-13 b. Asian

c. 14-17 c. Black or African American

d. 18-24 d. Native Hawaiian and Other Pacific Islander

e. 25-44 e. White

f. 45-54 f. Other

g. 55-59 g. Multi-race (two or more of the above)

h. 60-64 h. Unknown/not reported

i. 65-74 TOTAL (auto calculated) 0

j. 75+

k. Unknown/not reported 7. Military Status Number of Individuals

TOTAL (auto calculated) 0 a. Veteran Optional in SFY 2018

b. Active Military

3. Education Levels Number of Individuals c. Unknown/not reported

[ages 14-24] [ages 25+] TOTAL (auto calculated) 0

a. Grades 0-8

b. Grades 9-12/Non-Graduate 8. Work Status (Individuals 18+) Number of Individuals

c. High School Graduate/ Equivalency Diploma a. Employed Full-Time Optional in SFY 2018

d. 12 grade + Some Post-Secondary b. Employed Part-Time

e. 2 or 4 years College Graduate c. Migrant Seasonal Farm Worker

f. Graduate of other post-secondary school d. Unemployed (Short-Term, 6 months or less)

g. Unknown/not reported e. Unemployed (Long-Term, more than 6 months)

TOTAL (auto calculated) 0 0 f. Unemployed (Not in Labor Force)

g. Retired

4. Disconnected Youth Number of Individuals h. Unknown/not reported

a. Youth ages 14-24 who are neither working or in school TOTAL (auto calculated) 0

5. Health Number of Individuals

Yes No Unknown

a. Disabling Condition

Yes No Unknown

b. Health Insurance*

Health Insurance Sources

i. Medicaid

ii. Medicare

iii. State Children’s Health Insurance Program

iv. State Health Insurance for Adults

v. Military Health Care

vi. Direct-Purchase

vii. Employment Based

Module 4, Section C: All Characteristics Report - Data Entry Form


*If an individual reported that they had Health Insurance please identify the source of health

insurance below.

A.1. Total Number of INDIVIDUALS about whom no characteristics were obtained (DES added)

B.2 Total unduplicated number of HOUSEHOLDS about whom no characteristics were obtained. (DES added)

Optional in SFY 2018

Optional in SFY 2018







viii. Unknown/not reported

TOTAL (auto calculated) 0







D. HOUSEHOLD LEVEL CHARACTERISTICS9. Household Type Number of Households 13. Sources of Household Income Number of Households

a. Single Person a. Income from Employment Only

b. Two Adults NO Children b. Income from Employment and Other Income Source

c. Single Parent Female c. Income from Employment, Other Income Source,

d. Single Parent Male and Non-Cash Benefits

e. Two Parent Household d. Income from Employment and Non-Cash Benefits

f. Non-related Adults with Children e. Other Income Source Only

g. Multigenerational Household f. Other Income Source and Non-Cash Benefits

h. Other g. No Income

i. Unknown/not reported h. Non-Cash Benefits Only

TOTAL (auto calculated) 0 i. Unknown/not reported


10. Household Size Number of Households

a. Single Person

b. Two 14. Other Income Source Number of Households

c. Three a. TANF

d. Four b. Supplemental Security Income (SSI)

e. Five c. Social Security Disability Income (SSDI)

f. Six or more d. VA Service-Connected Disability Compensation

g. Unknown/not reported e. VA Non-Service Connected Disability Pension

TOTAL (auto calculated) 0 f. Private Disability Insurance

g. Worker’s Compensation

11. Housing Number of Households h. Retirement Income from Social Security

a. Own i. Pension

b. Rent j. Child Support

c. Other permanent housing k. Alimony or other Spousal Support

d. Homeless l. Unemployment Insurance

e. Other m. EITC

f. Unknown/not reported n. Other

TOTAL (auto calculated) 0 o. Unknown/not reported

12. Level of Household Income Number of Households 15. Non-Cash Benefits Number of Households

(% of HHS Guideline) a. SNAP

a. Up to 50% b. WIC

b. 51% to 75% c. LIHEAP

c. 76% to 100% d. Housing Choice Voucher

d. 101% to 125% e. Public Housing

e. 126% to 150% f. Permanent Supportive Housing

f. 151% to 175% g. HUD-VASH

g. 176% to 200% h. Childcare Voucher

h. 201% to 250% i. Affordable Care Act Subsidy

i. 250% and over j. Other

j. Unknown/not reported k. Unknown/not reported


E. Number of Individuals Not Included in the Totals Above (due to data collection system integration barriers)

1. Please list the unduplicated number of INDIVIDUALS served in each program*: Number of Individuals

F. Number of Households Not Included in the Totals Above (due to data collection system integration barriers)

1. Please list the unduplicated number of HOUSEHOLDS served in each program*: Number of Households

Below, please report the types of Other income and/or non-cash benefits received

by the households who reported sources other than employment

Program Name

Program Name







*The system will add rows to allow reporting on multiple programs.

